Health Outreach Approval Form
The purpose of this form is to collect information about planned student-led health outreach activities. The information collected can help to ensure the safety and legality of our students and University prior to the activity moving forward.

Please note that every health outreach activity needs to have this form submitted and approved prior to the event.

Please contact Dr. Larson (larso098@umn.edu) or Dr. Stratton (tstratto@d.umn.edu) with any questions or concerns regarding this process.

Email address *
Outreach activity name: *
Your answer
Student coordinator first name: *
Your answer
Student coordinator last name: *
Your answer
Student coordinator phone: *
Your answer
Additional contacts to include regarding follow up communications:
Please include names and email addresses of additional coordinators or contacts to be included should follow up or clarification be required.
Your answer
Registered Student Organization (RSO) affiliation: *
Please check all RSOs that are supporting or partnering on this event.
Required
RSO Faculty Adviser name: *
Your answer
Our RSO Faculty Adviser has been notified about this outreach activity at least 4 weeks before the event is scheduled to occur. *
Our RSO Faculty Adviser has reviewed, signed and dated all educational materials that will be used or distributed during the activity to ensure they are accurate and include the date of most recent revision. *
Please upload copies to the canvas site.
Activity description: *
Your answer
Activity location: *
Facility or organization, City, State
Your answer
Activity date: *
MM
/
DD
/
YYYY
Estimated start and end times: *
Military format: ex. starting 9am, ending 5pm (0900 : 1700)
Your answer
Classification: *
Please select all that apply.
Required
Services that will be performed: *
Please select all that apply.
Required
Please identify your target audience for health outreach services-choose all that apply *
Does this community require special considerations to ensure your event is appropriate, effective, or that unique needs be met? E.g. interpreter services, culturally appropriate materials, parent/guardian supervision, etc. Please discuss with your faculty adviser and/or supervisor.
Required
Estimated maximum number of event attendees and/or interventions provided: *
Not pharmacy student volunteers.
Your answer
Please list other community partners this outreach activity is held in collaboration with, if any.
Examples: mall, community group, church, pharmacy, etc.
Your answer
If the community partner is charging patients or billing insurance for services provided, please provide details below.
Your answer
Funding sources: *
Please select all that apply.
Required
Promotional materials used for advertising the event to the participants (not pharmacy student volunteer recruitment): *
Please select all that apply and upload copies to the canvas site.
Required
How many student pharmacists will participate? (Please break down the number of student pharmacists and their roles at the event. Ex. Pt. intake: 1 POC testing: 2 per shift, etc.) *
This will determine how many pharmacist supervisors are needed. Low Hazard Potential: No supervisor required; Medium Hazard Potential: Maximum student to supervisor ratio of 10:1. High Hazard Potential: Maximum student to supervisor ratio of 5:1. See supervisory guidelines on canvas site.
Your answer
I will upload the student attendance list to Canvas, including name, year, and campus for all students who signed up to participate in the activity PRIOR to the activity *
Please make a copy of the "Template: Health Outreach Student Pharmacist Attendance" sheet in Canvas, rename to include your activity name, and upload.
Is the Primary Supervisor UofM faculty? *
Please review the syllabus and Supervisory Guidelines documents in canvas to determine the hazard potential and ensure you follow supervisor requirements.
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